Happy Halloween!

Today is the day we celebrate witches and warlocks, toxic brews and zombies that come to life.  I like to think of witches and warlocks not as evil creatures but simply back yard chemists and drug users.  Much like the guy with a meth lab today.  The "flying" that has made witches famous.  Likely due to use of hallucinogens.  There are many people who think they can fly after taking drugs.  Why not witches?  The green color they are associated with?  The hallucinogens came from plants, green plants.  So they are green from grinding up jimson weed and flying around secondary to delirium.  But the broomsticks?  The broomsticks may have simply been a method of drug delivery.  It could have been an easy method getting drug to your skin.  Or the world's must uncomfortable suppository.  Either way, the broomstick could have been a way to take a drug.  But zombies, there is no explaining that, right?.  Maybe there is...  Haitian voodoo practitioners know how to extract the neuro toxin from puffer fish, tetrodotoxin.  The toxin causes paralysis of the face and extremities, speech impairment and slowed respirations.  Let's see... barely breathing, can't move your arms and face, can't talk. Sounds dead to me.  Now bury the victim.  Let the toxin wear off, dig him up and dead comes back to life.  Zombies!   

Today is also the day we celebrate costume parties, dressing up and trick-or-treating.  Take a minute to read these simple safety tips offered by the American Association of Poison Centers.     Most importantly be smart and be safe.  And don't let any voodoo doctors mix your drink!

 

 

 

 

 

 

Poison from the sky

October 30 is a great day.  Not only is it the day before Halloween, it is also the anniversary of the day of the first report published on the hooded pitohui.  (Science 258:799-801, 1992)  Hooded what?  The hooded pitohui is the only known venomous bird.  How awesome is that! 

The venom of the pitohui is similar to the poison found in dart frogs.  The venom is a neuro toxin that impacts sodium channels.  Its effects range from numb lips to being unable to breath and death. 

We all know that we never look up at birds flying overhead with our mouths open.  Now you have a new problem to think about.  Venom! 

Prison, Pruno and Poison

Prisoners have long been creative in their ability to access ethanol. Ten years ago hand sanitizer was the readily available source of ethanol. A few prisoners drank the sanitizer straight from the bottle with side effects from the glycerin. Others strained the sanitizer through socks and salt resulting in pure ethanol. Genius!

Now I read about "pruno" being the drug of choice in prisons. Is this brilliant biochemistry or just another way to harm yourself?

“Pruno, or prison wine, is an alcoholic liquid variously made from apples, oranges, fruit cocktail, ketchup, sugar, and possibly other ingredients, including crumbled bread. Bread supposedly provides the yeast for the pruno to ferment. Pruno originated in (and remains largely confined to) prisons and jails, where it can be produced cheaply, easily, and discreetly. The concoction can be made using only a plastic bag, hot running water, and a towel or sock to conceal the pulp during fermentation. The end result has been colorfully described as a "vomit-flavored wine-cooler", although flavor is often not the primary objective. Depending on the time spent fermenting, the sugar content, and the quality of the ingredients and preparation, pruno's alcohol content by volume can range from as low as 2% (equivalent to a very weak beer) to as high as 14% (equivalent to a strong wine).” http://en.wikipedia.org/wiki/Pruno Accessed 10/29/2012

I am sure many people have had positive effects from pruno over the centuries. A report published in MMWR (MMWR October 5,2012. Botulism from drinking prison made illicit alcohol. 61(39):782-784) illuminated an interesting side effect. At the Utah State Maximum Security Prison eight inmates were diagnosed and treated for foodborne botulism after consuming pruno.  All patients received antitoxin and three required mechanical ventilation.  None of the prisoners died.  Foodborne botulism comes from a toxin produced by the anaerobic bacteria, clostridium botulinum.   In this instance the bacteria came from a potato. 

So next time you are looking to brew your own.   Try to avoid any ethanol brewed in a garbage bag.

Garlic

Halloween is less than a week away.  Hopefully you have a cupboard full of garlic to ward off vampires. 

But what does it mean when you smell garlic?  Garlic odor is a sign of heavy metal poisoning, specifically arsenic and selenium.  So this Halloween think of the that nice neighbor that smells of garlic.  Are they hoarding garlic to keep the vampires away?  Of are they secretly poisoning the neighborhood with arsenic and selenium? 

In many parts of the country Sunday will the day for trick-or-treating.  Take the time to appreciate the joy and happiness that will be coming to your door.

Rock and Roll!

Today marks the anniversary of the first time the Rolling Stones appeared on the Ed Sullivan Show.  The October 25, 1964 show marked the entrance of the Stones as icons in rock and roll history. 

The Rolling Stones have long been linked to drug use.  Guitarist Keith Richards has written about his extensive abuse of a variety of substances.  Brian Jones, the original leader and guitarist of the band, was have heavy drug user before his death in 1969.   Check out Brian Jones on the harmonica during their Ed Sullivan set.   

And yet the band plays on...
 
The Rolling Stones live at Zilker Park, Austin Texas, 2006. Enjoy!

Energy Drinks

Energy drinks are an interesting part of our culture.  We use them in the morning to get started.  We use them in the afternoon to keep going.  We use them to get through long work shifts.  Then at the end of the day we mix them with vodka.  The use of energy drinks in various forms has been around for centuries.  Early Europeans drank coffee imported from Arabia and Turkey and tea that was imported from China.  Native laborers in the mountains of Columbia chewed coca leaves for energy.  During the civil war the North blockaded the South preventing the import of caffeine.  It is easy to see that energy drinks, be it my morning cup of coffee, or the afternoon Diet Coke enjoyed by many, are part of our culture. 

As with any drug there is always a downside.  In 2010 US poison centers assisted in the management of over 500 patients that were exposed to an energy drink.  Of those five had a life threatening event.  Fortunately, none died.  Today it was reported that the FDA had received reports of five deaths secondary to consuming energy drinks.   Here is a link to the New York Times article.   Caffeine has a well known list of side effects.  A little to much caffeine and we can all get jittery and have an upset stomach.  Not to mention the feeling that your heart is racing.  But what if you take a giant dose, or have a preexisting heart condition.  In those situations the outcome is not good. 

A drug being part of our culture is not a bad thing.  Most of the time it is a really good thing.  But it is important to remember that all drugs, including caffeine and energy drinks, have side effects.  Plus some people should never take some drugs.  As our Friends at Erowid.com tell us, "Know your body - know your mind - know your substance - know your source."              

 

Politics and Poisoning, US style...

Today is the last Presidential debate for 2012.  We are sure to witness attacks by each candidate and elaborate stories thrown out in an ingenious defense.  The only poison we will witness will be in the form of venomous words.    But the use of poisonings to influence politics has been going on for centuries.  From Alexander the Great to Caesar Augustus and Napoleon Bonaparte, poisoning for power has long been practiced.  Viktor Yushchenko told us the poisoning to change elections still exists in this, the 21^st century.  But certainly poisoning for political gain would never happen in this country.   

The Dalles, Oregon is a quaint community of nearly 13,000 that lies on the banks of the Columbia River.  It is the county seat of Wasco County in northern Oregon.  Back in 1981 the local Big Muddy Ranch was sold and within three years became a thriving religious community.  The ranch was incorporated as a city, Rajneeshees.   At its peak the city had a population of 7,000 followers of Bhagwan Shree Rajneesh.  It did not take long for the new city to be embroiled in a string of disputes with the nearest city, Antelope Oregon, and the county.    

In 1984 the followers of Rajneesh ran for election in two of the open seats on the Wasco county circuit court.  Fearing that they did not have enough votes to win Rajneesh followers decided to influence the electorate in an unusual way.  Today we see attack ads that may sometimes contain a small kernel of truth.  But that is child’s play.  Rather the followers of Rajneesh made the concerted effort to limit the number of voters by poisoning many local salad bars with salmonella. 

First two Wasco county commissioners were deliberately poisoned and became ill, one was hospitalized.  Next salmonella was spread on the doorknobs and urinal handles in the courthouse.  But again, not enough people became ill.  The community then spread salmonella on ten different salad bars through the city.  According to a paper published in JAMA in 1997 that details the public health investigation, 751 people became ill.  The poisoning occurred in two waves and lasted from September 9 to October 10.  After ruling out all of the normal modes of disease transmission it was confirmed that the mass poisoning was caused by a single strain of salmonella typhimurium.   The bacterium was found in stool samples of the ill, on the food from the restaurants and in the laboratory of the commune.  Common symptoms of the victims included fever, chills, abdominal pain, nausea, vomiting and diarrhea.  The victims ranged in age from a newborn to an 87 year-old.   ( Török TJ, Tauxe RV, Wise RP, et. al.  A Large Community Outbreak of Salmonellosis Caused by Intentional Contamination of Restaurant Salad Bars.  JAMA. 1997;278(5):389-95) 

So what happened to the election?  When rumors spread throughout Wasco County that the commune was behind the poisonings, voters showed up in big numbers.  The Rajneeshees eventually withdrew their candidates from the ballot.  The terrorist plot was foiled.    

Poisoning and politics.  Will we be reading next month of an election influenced by the verbal poison of the candidates and the venom of special interest groups?  Hopefully we will not be reading about a power grab made with the assistance of one of life’s oldest political friends.   And yes, it can even happen in your backyard.

Clean Water

Today marks the 40th anniversary of the Clean Water Act. Worldwide the lack of clean water is a tragedy that leads to the death of millions every year.  Be it swimming, fishing, boating or just brushing your teeth, we can all be grateful for a law that was passed by a wise US Congress a generation ago.  Here is a brief summary of the Clean Water Act.   

Banker getting high

Clearly the use of illegal, and legal, drugs to get high is for the young and foolish.  It seems to be a monthly news item, "13 year-old ingests "bath salts" and is hospitalized; friend is arrested."  On Monday a similar, but not so similar story surfaced.  The story revolves around Brian Mulligan, a former FOX TV Chairman and current VP for Deutsche Bank.   The standard investment banker beat up by police story quickly unravels.    Mr. Mulligan's own version is entertaining all by its self.  Enjoy this article and video, especially the audio tape of Mulligan.   Not your normal teenager checking out what's new at the head shop. 

Bath salts are not for your bath.  They are synthetic cathinones.  Imagine a high potency and very dirty methamphetamine.  "White Lightning" was consumed in large amounts by Mulligan.  He experienced effects that were not unusual.  You have to appreciate that he was hearing helicopters and they were after him.  This article from WebMD gives great information on Bath Salts.   Today bath salts are illegal by Federal law and illegal is most states.  But they persist.  They are still available over the Internet.  Plus new versions hit head shops every day.  Unfortunately the problem is not going away.

So Brian Mulligan, good luck with your lawsuit against the LAPD.  Maybe you should leave getting high on bath salts to teenagers.                

Politics and Poison Elections

Poison and politics. Surely poisonings happened centuries ago. But really, this is 2012, nothing like that happens anymore.

 

Viktor Yushchenko was the hope for the people. He was a young, dynamic, good looking candidate who was unafraid to take on the establishment. The year was 2004 in the Ukraine. Yushchenko was the informal leader of the “Orange Revolution”. In 2004 the independent rival candidate to the sitting President was prevented from taking his campaign to the airways by the government. His campaign was therefore built on face to face communication. Then the unthinkable happened. The people’s candidate became gravely ill in September 2004. Originally diagnosed with acute pancreatitis Yushchenko maintained from the beginning he was poisoned by government agents. When he returned to the campaign Yushchenko was badly disfigured. It was postulated that the changes in his face were consistent with chloracne secondary to dioxin poisoning. Subsequent lab testing showed Yushchenko had blood level of dioxin 6,000 times higher than normal. He was poisoned with TCDD dioxin. The delivery of the poison was linked to dinner between Yushchenko and a group of senior Ukrainian officials. The Lancet (August 2009) published a paper on the kinetics of TCDD in Yushchenko. His 2004 TCDD serum levels were 50,000-fold greater than those in the general population.

 

The poisoning theory has been argued both pro and con. Some say Yushchenko poisoned his lab samples, or even poisoned himself. Others say no, he was poisoned by the government in an effort to disfigure him so that he would no longer appeal to young voters. The argument still rages today.

 

As for Viktor Yushchenko, he won the election after a court ordered recount. He took office in January 2005 as the President of the Ukraine.

 

Wednesday's Exam

Some thoughts for our exam on Wednesday...

1. You will not have to know antidote dosing.  You have an app for that!
2. You do not have to know the incidence of poisoning from AAPCC data.  That was for background only.
3. You do need to know how each antidote works together with indications and contraindications.  Adverse effects are probably important too.
4. You should know the clinical presentation, treatment and mechanism of toxicity for each of the categories of meds that have been presented.

Good luck! 

Politics & Poison, Part II

“Et tu, Brute”

What one person will do to gain power has no bounds.   For Julius Caesar it was an attack by Senators and his friend, Marcus Brutus.  In the decade before Christ was born Caesar Augustus was the Emperor of Rome.  It was Augustus that gave birth to the Roman Empire.    Caesar Augustus died in 14 AD and was succeeded by his stepson (and former son-in-law) Caesar Tiberius.   It is thought that Augustus was poisoned by his wife, Livia.  Livia them put her son on the throne and ruled Rome through him. 

Napoleon Bonaparte is a famous French military and political leader.  He rose to power during the later stages of the French revolution.  He went on to be Emperor of France from 1804 to 1815.  Napoleon led the French to war on many fronts.  It was his invasion of Russia that started his downfall.  The other European nations built a force to oppose him.   In 1813 he was defeated at Leipzip and retreated into France.  In 1814 France was invaded and Napoleon forced to abdicate his throne.  He was exiled to the island of Elba.  But he came back.  He escaped from Elba, rallied the French and reclaimed the throne.  But then the Battle of Waterloo; Napoleon was defeated once again and this time exiled to the island of St. Helena.  It was there that Napoleon died in 1821.  It has long been thought that Napoleon was poisoned and killed with arsenic.  What better way to keep the Emperor from returning? 

 Where is politics without love?  King James IV of Scotland had a mistress, Margaret Drummond.  There is thought that King James was secretly married to her.  They did have one child together.  But at the time there were people in both England and Scotland who felt that James should marry the daughter of King Henry IIV, Margaret Tudor, thereby uniting Scotland and England.   Poor Margaret Drummond stood in the way, and she was poisoned.  With her death King James married Margaret Tudor in 1502 and 100 years later Scotland and England were truly united.

Be it a mother’s love for her son or a King’s love for his land; love, politics and poison make interesting bedfellows. 

Poison by Cockroach

Let's face it.  Winters may be harsh in Wisconsin but the bugs are wimpy.  In Texas we had roaches the size of an iPhone and crickets that needed to be cleaned up with a bobcat.  Arizona adds in scorpions.  But Florida may top it all.  On Monday a guy in south Florida went on a roach and worm eating binge in an effort to win a python (How many things are wrong in that thought process!).  After going on his binge the poor guy walked out of the store, collapsed and died.  No mention of what happened to the python.  It is such a great story even our Milwaukee paper covered it.  

 

There is nothing inherently toxic about roaches or worms.  They may carry disease, but even that is unlikely.  It will be interesting to hear the autopsy report/labs on this unfortunate gentleman.   Did he choke on the excess protein?  Maybe aspirated a bunch of legs.  My guess is that there may be other chemicals involved.  Maybe some ethanol?  Maybe with a benzodiazepine chaser.  A favorite intoxicant of Texas snake bite patients was meth.  Who knows....

Two things I do know...  No way do we eat worms and roaches sober and I will happily take on the winter.       

Whatever happened to enjoying a fine snifter of port and calling it a night?

Alternate title: "Kids these days..."

Reaching legal drinking age is considered a rite of passage across cultures and generations. For many Americans,* the 21st Birthday can be cause for raucous celebration. English young adults get to celebrate at 18; this is clearly due to class and sophistication that dominates their culture.

The need to incorporate elegance and grace into every aspect of daily life permeates into the Birthday Ritual as well. Many bartenders (aka mixologists) have dedicated their careers to experimenting with creative new approaches to serving spirits. Sure, the shaken-not-stirred vodka martini has a classic James Bond-ian feel to it, but it doesn't quite command a room the same way as a flaming shot of 151!

It is therefore interesting to note that the field of Mixology, the study of designing and serving mixed drinks and cocktails, actually mirrors that of compounding pharmacy: understanding how the proper substances, mixed in the proper proportions and delivered in just the right way, will produce a desirable end effect. Compounding pharmacists understand that improper use of pharmaceuticals can have disastrous consequences, however; a recent news story suggests mixologists are becoming more aware of the field of Toxicology.

Celebrity chefs, master mixologists and medical experts from around the world are steamed up about a report that a British teenager had a portion of her perforated stomach removed after ingesting liquid nitrogen in a trendy cocktail. 
http://abcnews.go.com/Health/liquid-nitrogen-cocktail-injury-steams-debate-flashy-drinks/story?id=17425885#.UHRWUkf_dCA

Though the toxicological impact of improper administration of a flaming shot should be fairly self-explanatory, ingestion of liquid nitrogen can potentially cause frostbite-like symptoms within the upper-digestive tract. As this story suggests, it appears that an English teen was given a shot of Jaegermeister that had been chilled using liquid nitrogen cooled to below -300F. The ultra-cold temperature would have caused her stomach lining to solidify, allowing the "boiling" nitrogen to cause a massive increase in pressure, leading to rupture. It is clear that, given the global reaction this story has already produced, much more information about this situation will be learned in the days and weeks to come.

Does this mean bartenders shouldn't be allowed to use liquid nitrogen anymore? Of course not! It just means we toxicologists have an opportunity to educate the public on the proper administration of wine and spirits. Which is, I'm sure, exactly what a young adult wants to hear when celebrating at the pub.

* Because I was living in Germany at the time, I was able to enjoy my first legal ale at the Hofbrauhaus in Munich at age 16.

Patron Saint of Pharmacists

The Saint of the Day for October 9 is St. John Leonardi.  He was a pharmacist who decided to pursue the priesthood. 

"John Leonardi was born in 1541 in Diecimo, in the province of Lucca. The last of seven siblings, his adolescence was sprinkled with rhythms of faith lived in a healthy and industrious family group, as well as the assiduous frequenting of a shop of herbs and medicines in his native town. At age 17 his father enrolled him in a regular course in pharmacy in Lucca, with the aim of making him a future pharmacist, that is, an apothecary, as they were called then. For close to a decade young John Leonardi was vigilant and diligent in following this, but when, according to the norms established by the former Republic of Lucca, he acquired the official recognition that would have allowed him to open his own shop, he began to think if perhaps the moment had not arrived to fulfill a plan that he had always had in his heart.

After mature reflection he decided to direct himself toward the priesthood. And thus, having left the apothecary's pharmacy, and acquired an appropriate theological formation, he was ordained a priest and celebrated his first Mass on the feast of Epiphany of 1572. However, he did not abandon his passion for pharmaceutics because he felt that professional mediation as a pharmacist would allow him to realize fully his vocation of transmitting to men, through a holy life, "the medicine of God," which is Jesus Christ crucified and risen, "measure of all things."  

Animated by the conviction that, more than any other thing, all human beings need such medicine, St. John Leonardi tried to make the personal encounter with Jesus Christ the fundamental reason of his existence. It is necessary to "start anew from Christ," he liked to repeat very often."

  Pope Benedict XVI, October 7, 2009

Coral Snake Envenomation

16 years ago I arrived in Texas with a total experience of two patients who had been bitten by venomous snakes.  My first week I was called on six patients.  Welcome to April in Texas.  Since that time I was involved in the management of hundreds of snake bite patients.  One of my memories from Boy Scouts was learning, "Red on Yellow, kill a fellow, red on black venom lack".  Many of you learned the same rhythm.  All the text books tell us to treat coral snake bites with antivenom regardless of symptoms.  Their bite will "kill a fellow".  And that coral snake venom is the most toxic venom in the US.  Interestingly, no one ever seemed to get sick from a coral snake bite.  The only really sick patients I heard about had an adverse reaction to the antivenom.  Over a number of years we published numerous research abstracts and one paper on the Texas coral snake.  Our recommendation; do not treat people bitten by coral snakes with antivenom.  Coincidentally the current manufacturer of antivenom (Wyeth) ceased making it.  But in Florida, where a different coral snake species lives, the use of antivenom continued. 

Last week two fascinating developments occurred in the coral snake treatment saga.  First, the last few remaining supplies of antivenom had their expiration date extended by the FDA through October 31 of this year.  Good news, at least for a few weeks.  Second, a group of toxicologists in Florida presented their work on coral snake bites at the North American Congress of Clinical Toxicology.  They presented 12 years of data, 387 patients.  As expected the majority of patients were males bitten on their fingers and hands.  (There was no comment on co-ingestants, i.e. ethanol.)  65 % of the patients were given antivenom.  18.5 % of those had an adverse reaction.  Of interest, asymptomatic patients given antivenom when they initially arrived in the ED had the worse outcomes.  Those patients given antivenom only when they developed symptoms did better.  So following the textbook was bad for the patient.  Maybe Florida and Texas snakes are not so different after all. 

To give your patient antivenom or not, the controversy will remain.  Old practice habits die hard.  But ultimately it will make no difference, we won't have any antivenom to give.    

Agitation and Alcohol

Care of the ethanol intoxication, from agitation to withdrawal, is a topic of ongoing discussion.  Some nice person ends up in the ED extremely intoxicated and agitated.  What to do? Some would argue for an antipsychotic to control agitation.  Effective? Very, but those are laden with side effects.  Others argue for benzodiazepines.  They are effective and safe.  Most fall to using benzos.  But the argument continues to rage.  More research needs to be done.

But what about the chronic alcoholic going through acute withdrawal.  Again benzodiazepines are the drug of choice.  They are safe even in extremely large doses rarely causing respiratory depression.  Unfortunately there is a subset of patients that are benzodiazepine resistant.  There are many intensivists that prefer to use dexmedetomidine off-label.  But the data on its use is scarce primarily case reports and case series.  As a selective alpha-2 adrenergic agonist it makes since.  It is sedating and controls the tremor, hypertension and tachycardia. There are also many who prefer the off-label use of ketamine for those difficult to manage patients.  Ketamine is a NMDA blocker.  Of course the data on it is in short supply but it is safe and appears to decrease the amount of benzodiazepines required and length of stay. 

Just another fascinating discussion in the world of clinical toxicology. 

Randomized Controlled Trials

The world of clinical toxicology is a minefield of case studies, anecdotes and opinions.  Rarely is there a randomized control study anywhere to be found.  The ethics of poisoning someone, randomizing them to a treatment or no treatment arm and recording results is apparent.  That study is extremely difficult to design. 

The Extracorporeal Treatment in Poisoning (EXTRIP) is a group of toxicologists, pharmacologists, nephrologists and others who are developing guidelines on the treatment of a variety of toxins.  Their work on lithium and valproate intoxication was fascinating.  The groups reviewed all the existing literature, over 1,200 papers, as background to a evidence based guideline.  They readily dismissed most papers and closely evaluated around 130 for each guideline.  How many were randomized controlled trials?  none.  The definitive treatment for lithium toxicity is hemodialysis.  Yet there is not a single trial to demonstrate benefit. 

In August 2011 a new antivenom for the treatment of scorpion stings received FDA approval.  The approval was partially based on a single randomized control trial in Tucson.  Fifteen children were enrolled and eight received antivenom.  Fascinating.  Of interest is that no other hospital in Arizona would take on the study due to ethical concerns.  And when the study showed the new antivenom to be a resounding success, they could not ethically continue the trial.  How can you give a placebo to a child when you know there is a proven successful treatment.     

Randomized controlled trials in toxicology.  It is a world befuddled by ethical concerns and a desire to do the best for unfortunate patients. 

 

Politics and Poisoning Part One

Poisons have been  used to change political environments since man first walked on earth.  This year we are in the midst of fierce local, statewide and national elections.   To celebrate I will write a brief entry on each presidential or vice-presidential debate day.  Tonight when President Obama squares off with Governor Romney you can sit back, enjoy the rhetoric and think poisons.

As long ago as 336 BC King Artaxeres III of Persia was murdered by his chief minister Bagoas.  Bagoas wanted to place Artaxeres IV on the throne, a king he could easily control.  When King Artaxeres IV started to push his independence Bagoas poisoned him too elevating King Darius to the Persian throne.  But Darius proved too sharp for Bagoas.  When Bagoas attempted to poison Darius the tables were turned and Bagoas drank the poison instead.    

Alexander the Great (Alexander III of Macedonia) died in 323 BC in the palace of Nebuchadnezzar II, in Babylon, at age 32.  It is said that Alexander entertained admiral Nearchus and spent the night and next day drinking wine with Medius of Larissa.  Alexander rapidly developed fever, muscle weakness and pain.  He died in agony 14 days later.  Antipater, who was recently removed as Macedonian viceroy, and at odds with Olympias, was  fingered by many as leader of the plot.  Antipater purportedly arranged for Alexander to be poisoned by his son Iollas, who was Alexander's wine-pourer. Another theory is the Alexander died of poisoning from drinking the bacteria infested water from the river Styx.   

Poisoning for political gain has existed since long before the time of Christ.  Next week we will jump ahead 1,000 years for a couple more fascinating poisonings.  

 

 

 

 

Lipid Emulsion

Today I had the opportunity to sit and listen to an Aussie talk about lipid emulsion therapy.  But he did not just talk about what we know and review the literature.  Rather he talked about lipid emulsion therapy 2.0.  He presented his research into liposome therapy.  He is using phospolipids to sequester various agents.  Imagine a sphere with a hole in the middle.  The outside is the charged, phosphate layer.  The inner ring the lipid area.  The innermost core is an area whose pH can be manipulated.  By manipulating the core pH, the charge of the phosphate layer and the size of the lipid layer a variety of drugs are trapped.  In the future will we be seeing liposomes used to increase dosages of cancer chemotherapeutic agents?  Treat toxins that today we can only weep over?  If we do; you heard it here first. 

Along the lines of lipid emulsion therapy there are no less than eight abstracts at this toxicology meeting lauding its use.  There is a wide variety of toxins that were treated.  All very fascinating.

Phenytoin Toxicity and Multidose Charcoal

Three weeks ago the toxicity of antoconvulsants was presented.  The clinical picture of a patient taking phenytoin and developing toxicity was laid out, and it was not pretty.  Initially ataxia, nystagmus and lethargy that can progress to seizures and coma.  The difference between a therapeutic serum phenytoin level and a toxic one is small.   There is some evidence that in the symptomatic patient who took an acute overdose multidose charcoal may be beneficial.  Today in my mailbox is the latest issue of Clinical Toxicology.  In it is a paper that attempts to quantify the effect multidose charcoal has on patients with a supratherapeutic serum level of phenytoin.  Clinical Toxicology Paper (Abstract).               
A few items of interest.  This is a randomized controlled study lasting 18 months involving two large teaching hospitals.  Pretty great for a tox study.  But they could only enroll 17 patients.  Pretty typical.  They showed that there was a difference in time to a sub-toxic serum concentration between the study and control groups.  Great!  With a larger number of patients they may have been able to show a significant difference.  Even better.

What to take away from this study?  Clearly more study with more patients is required.  Studies that looked at clinical parameters in addition to time to sub-toxic levels would be a plus.  Based on this paper alone is it hard to change clinical practice.  What this does do is make it easier to recommend multidose charcoal is the appropriate patient.  It is one more piece in a larger clinical puzzle.